Medicaid Enrollment Is Brisk Despite HealthCare.gov Troubles

Low-income adults formerly had few options for free health care. Leah Sessor had her blood pressure taken on April 14, 2012, during a free clinic at a racetrack in Bristol, Tenn.

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Originally published on November 20, 2013 11:16 pm

Buried in the paltry enrollment numbers for the Affordable Care Act that were released last week was something that came as a surprise to many — the success states are having signing people up for the Medicaid program, which provides health care to low-income people.

During the first month the health exchanges were open, just over 100,000 people managed to choose a private health plan, according to the report. But nearly four times as many were deemed eligible for Medicaid or actually enrolled in that program or its cousin, the Children's Health Insurance Program.

But people who have been working on the Affordable Care Act say that's neither a surprise nor a fair comparison.

"Comparing those numbers today is like comparing apples to baseballs," says Joan Alker. She's executive director of the Georgetown University Center for Children and Families.

One major reason for the brisk early enrollment in Medicaid is that many states have made it a point to reach out early to people they assume will be eligible, such as those already getting other benefits like food stamps.

In Arkansas, Alker says, "the newly eligible received a letter in the mail, and they simply had to sign and return that letter in order to enroll. So does that sound like the exchange enrollment process to you? No, it doesn't."

But it's not just states that are expanding their Medicaid programs that have people signing up for Medicaid. States that have refused federal funds to expand their Medicaid coverage (about half of states are expanding and half are not) are seeing more people coming forward, too.

Advocates for the program call it the "welcome mat" effect. But it's more commonly called the "woodwork effect."

"At any given time, only two out of three people who are eligible for Medicaid are enrolled," says Michael Cannon, director of health policy studies at the libertarian Cato Institute. "And so if you have this big expansion with this big media education campaign, a lot of those people who are already eligible will go and enroll in the program."

"The federal government is paying on average a little more than half of the cost for that; so states are paying a little less than half of the cost," Cannon says. He is an opponent of the health care law.

Not only will states have to pay more for these newly enrolled people, Cannon says, but putting more people on Medicaid is not necessarily a good thing. He says many have questioned whether it's a very good program at all.

"The access to care and the quality of care in Medicaid is not what it should be, and so there's a big question about health outcomes of Medicaid and how do they compare to private insurance and even not having health insurance," he says.

But at least some of those questions have been answered in a series of studies done in Oregon.

"It seems clear that there are substantial benefits for low-income adults who enroll in Medicaid relative to being uninsured," says Katherine Baicker of the Harvard School of Public Health. She's one of the lead researchers of the studies.

Low-income adults on Medicaid had an easier time getting health care, Baicker says. They also used more health care and had far fewer financial problems than those who remained uninsured.

"We saw big drops in depression rates for people who got Medicaid relative to being uninsured," Baicker says. People also said their health was better.

But one of the goals of the Affordable Care Act was to expand health insurance to millions more people, including through the Medicaid program. It just happens to be the one where enrollment is working at the moment.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.

Transcript

MELISSA BLOCK, HOST:

From NPR News, this is ALL THINGS CONSIDERED. I'm Melissa Block.

ROBERT SIEGEL, HOST:

And I'm Robert Siegel. It's been a month and a half since the new federal and state health insurance exchanges opened, and much has been made of how slowly people are signing up for private health coverage. But it's a very different story among low-income Americans signing up for Medicaid.

In the same month and a half, enrollment in the program has been brisk and that's true even in states that aren't expanding Medicaid. NPR's Julie Rovner explores why.

JULIE ROVNER, BYLINE: The numbers released last week by the Obama administration were a revelation to many. During the first month the health exchanges were open, just over 100,000 people managed to choose a private health plan. Over the same period, nearly four times as many were deemed eligible or actually enrolled in Medicaid or its cousin, the Children's Health Insurance Program.

But people who have been working on the law say that's neither a surprise nor a fair comparison.

JOAN ALKER: Comparing those numbers today is like comparing apples to baseballs. They're just not similar at all.

ROVNER: Joan Alker is executive director of the Georgetown University Center for Children and Families. She says one major reason for the brisk early enrollment in Medicaid is that many states that are expanding the program made it a point to reach out early to people they assume will be eligible, such as those already getting other benefits like food stamps.

The health law allows, for the first time, everyone up to 133 percent of poverty to qualify for Medicaid. That's about $15,000 for an individual. And some states are making it very easy to sign up.

ALKER: So, for example, in Arkansas, the newly eligible received a letter in the mail, and they simply had to sign and return that letter in order to enroll. So does that sound like the exchange enrollment process to you? No, it doesn't.

ROVNER: Indeed, Oregon has already signed up more than 70,000 people for its expanded Medicaid program, and its online health exchange is still not yet up and running. But it's not just states expanding the program where people are signing up for Medicaid. States that have refused the health law's expansion are seeing more people coming forward, too. It's something called the woodwork effect, says Michael Cannon. He heads health policy studies at the libertarian Cato Institute.

MICHAEL CANNON: At any given time, only two out of three people who are eligible for Medicaid are enrolled, and so if you have this big expansion with this big media education campaign, a lot of those people who are already eligible will go and enroll in the program.

ROVNER: Which is why in places like Florida and Texas, the exchanges have already qualified more than 10,000 new Medicaid enrollees each. In states that are expanding the program, the federal government is footing nearly all of the bill. But Cannon notes that for people who were previously eligible, states will have to pay their regular share of Medicaid costs.

CANNON: The federal government is paying on average a little more than half of the cost for that; so states are paying a little less than half of the cost.

ROVNER: Cannon, who is an opponent of the health law, says that not only will states have to pay more for these newly enrolled people, but putting more people on Medicaid is not necessarily a good thing. He says many have questioned whether it's a very good program.

CANNON: The access to care and the quality of care in Medicaid is not what it should be, and so there's a big question about health outcomes in Medicaid and how do they compare to private insurance and even not having health insurance.

ROVNER: But at least some of those questions have been answered recently in a series of studies done in Oregon. Katherine Baicker of the Harvard School of Public Health is one of the lead researchers.

KATHERINE BAICKER: It seems clear that there are substantial benefits for low-income adults who enroll in Medicaid relative to being uninsured.

ROVNER: Baicker said her studies found low-income adults in Oregon who got Medicaid had an easier time getting health care, used more health care and had far fewer financial problems than those who remained uninsured.

BAICKER: We saw a big drop in depression rates for people who got Medicaid relative to being uninsured, and big improvements in self-reported health.

ROVNER: Medicaid might still be controversial, but one of the goals of the Affordable Care Act was to expand health insurance to millions more people, including through the Medicaid program. It's just the one where enrollment happens to be working at the moment. Julie Rovner, NPR News, Washington. Transcript provided by NPR, Copyright NPR.